South Central VA Health Care Network (VISN 16)

Issue: Employee states she found her personal lab work in her supervisor's desk drawer, removed the lab work, and took it to the CBOC Medical Director. Update: 1/16/13:Further investigation showed supervisor inappropriately accessed employee's CPRS record. Referred to supervisor and LMR…

Outcome: Referred to supervisor and LMR for appropriate disciplinary action.

Issue: It was reported to the Information Security Officer (ISO) that a competency folder containing personal information (Social Security Number and possibly date of birth (DOB) on one of our employees has been lost. The competency folder, including her performance appraisal,…

Outcome: Supervisor and Administrative officers will continue searching for the folder and notify the employee if/when it is located. They are aware these folders need to be in a secured area.…

Issue: The facility received a letter from Veteran A who stated he had received Veteran B's medical record. Records were mailed to the wrong address. Release of Information office will be forwarding a self addressed, metered envelope to Veteran A so…

Outcome: Employee counseled and instructed to completer refresher training. -- Credit monitoring letter sent out.

Issue: A Veteran received his medical records per his request, but also received the medical records of three other Veterans in the envelope with his documents. Update: 12/16/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: QM will evaluate and address the procedural and quality and control issue this indicident reflects.

Issue: The Service Chief accessed a Veteran's record who is a potential employee. The Service Chief reviewed the service connection status of the Veteran. Update: 01/131/12:The Veteran will receive a letter offering credit protection services.…

Outcome: Training and the appropriate administrative action has been taken in accordance with human resource policy.

Issue: Evidently a Medicine Team Member left the report for 10 patients in a patient's room on 6D sometime between 12/13/11 and this morning when a rounding nurse found it. The report contains the 10 patients' last name, last 4 digits…

Outcome: The Service Chief has met with residents that are a part of the team that had left the information. He also had another meeting the with Chief Residents and instructed them to discuss the importance of protecting patient information ....…

Issue: Veteran A came into the Ozark CBOC saying he received Veteran B's prescription and provided the name of the patient. He was told to take the medicine to the closest VA to be destroyed. Information disclosed was name, address and…

Outcome: Pharmacy has started a review process to catch such errors and hopefully this will eliminate such happenings.Service is very aware of the importance of maintaining patient privacy and will continue to educate staff

Issue: A VA employee found the list with patient information in the cafeteria. The list contain patient's full name, DOB, full SSN, and medical information. Update: 12/12/11:The list was an in patient listing with full name, SSN, room number and other…

Outcome: Nurse Manager is trying to identify the employee responsible for leaving the list and will take the appropriate action.

Issue: Veteran A was in the facility on 10/17/11 and he apparently received an appointment letter for Veteran B. Veteran A and Veteran B share the same last name and last four digits of their SSN. Veteran A received Veteran B's…

Outcome: Staff are unable to tell exactly who made the error. Clerks from 2 different areas were involved with the patient's care on that day. The Privacy Officer has talked with both services and asked that all be current on privacy…

Issue: Veteran A called the clinic and informed them that he received his appointment letter and there was a letter for Veteran B with his. The letter contained Veteran B's name, address, partial SSN and appointment information. Update: 11/30/11:Veteran B will…

Outcome: Supervisor counseled volunteer to be more careful when stuffing letters.